Googling My Patients

A thoughtful friend recently pointed me to this New York Times essay by a physician-in-training, Dr. Warraich. She discusses the ethical ramifications of Googling her patients for information beyond what she could obtain through a traditional face-to-face history and physical examination. The author believes doctors should resort to such third-party sources of information only when there is a “safety issue”.  Well, yes. But.

Leave aside for now that “safety issue” is a pretext that could be stretched like a latex exam glove to cover a meaty fistful of iniquity. Dr. Warraich and I both stipulate good intentions; for considerations of ethics, intentions matter more than results. But after years of making critical decisions, too often with incomplete information, I’d never want to arbitrarily exclude Google, or any other potentially useful source, out of an erroneous sense of ethical unease. The ethical conundrum arises not in obtaining information, but in deciding how that information will be used to further the therapeutic goals of the doctor-patient relationship. The issue is power and its exercise, not the information per se, or how it’s obtained.

While Dr. Warraich and I agree that Google shouldn’t replace an actual face-to-face history and physical exam, there are circumstances in which your clinical “Spidey sense” — refined over decades of training and practice, and ignored at your peril — tells you that something is just not right.  With the patient unwilling or unable to cooperate, and family members unavailable or clueless, supplementing the “H & P” with further information, however you can get it, is the right thing to do.

Dr. Warraich cites two such cases. In the first, a patient tried to talk her way into a double mastectomy for a nonexistent illness. In the other, a surprise laboratory test result pointed to an undiscovered history of substance abuse. In both patients, clinical impressions did not jibe with hard data; information gleaned from web searches enabled the medical teams to do the right thing for the patients. The first patient’s caregivers thereby avoided unnecessarily operating on her; one hopes that they were able to get her the psychiatric care she obviously needed. In the second case, Dr. Warraich’s recounting leaves me uncertain whether the substance abuse was directly related, or merely incidental, to the patient’s current illness. Regardless, she recovered uneventfully.

Dr. Warraich chose not to confront the second patient with her internet findings, when the confrontation wouldn’t have advanced the therapeutic cause. She need not feel she “violated [the] patient’s privacy” in resorting to Google, through the purest of intentions, to obtain those findings. Once in possession of the information, she declined to exercise simply for its own sake the unequal power it gave her over her patient. That sounds like ethical doctoring, not cause for hand-wringing.


Why I Don’t Treat My Own Kids

Sitting in the living room, head down in my laptop, I was largely oblivious to the kitchen’s conversational murmurings. But it seeped into my consciousness that my daughter, days on, was still feeling poorly. She described a few days of headache, nausea, malaise, vague aches and pains, and fatigue. No definite fever, but a sore throat and a stuffy head lingered.

Any kid raised by healthcare professionals, among whom E.R. nurses and doctors of any stripe are the worst, will tell you that we are tough arbiters of what constitutes “sick”. Quotidian aches and pains? Nice try, but you’re going to school. Flu? Why bother with a trip to the doctor’s pestilent waiting room, when she has so little to throw against that torment? Crushing, radiating substernal chest pain in an immediate family member? Obviously indigestion; take some Maalox so I can finish my book in peace. Only a kitchen knife, quiveringly embedded in a skull, pulsatile hemorrhagic jets, or limbs bent at anatomically impossible angles will get much of a rise out of the medical parent. Even then, we will suspect malingering.

I did pause long enough to run through a mini-differential diagnosis. Rejecting flu, cholera, typhus, ague, pleurisy, Ebola virus, tertiary syphilis, and Naegleria fowleri amoebic brain abscess, I came up with mononucleosis,  because I vaguely recalled from my pediatric rotation in the 1980’s that, among older teens, “mono” is common enough to have a nickname, and presents symptoms at least overlapping hers. Even better, it’s almost never fatal, so I could dismiss this self-limiting problem and still feel smug in my knowledge.

Did I examine the patient? Surely you jest. Any reader with a teenager knows they behave like truculent baboons under examination by their parents, medical degree or not. God forbid you should interrupt their tweeting fingertips to muss the hair or rumple the carefully-arranged clothing as you feel for the enlarged cervical lymph node. And who knows where I put my antique oto-ophthalmoscope set, purchased in medical school, with its long-dead, non-standard NiCad battery pack. Instead, I did the sort of dart-board diagnosing, if only in my mind, that qualifies as malpractice elsewhere.

Therefore, mom took daughter to the pediatrician the next day, who properly examined the patient and discovered a sinus infection. Purulent nasal discharge, fluid levels behind inflamed eardrums; oh, yeah, hadn’t thought of those. The doc thought so little, evidently, of my clairvoyant diagnostic surmise that she didn’t even do a Mono-spot. Antibiotics were purveyed, school release printed, and that was that. The patient is improving despite her father’s ministrations.

The old saw holds that the person who treats himself has a fool for a physician, and more so when you’re doctoring family members. For one, primary care is simply not my field of expertise. But further, the heart refuses to ponder that anything evil might ever be wrong with a dear one, so your medical mind glides over the awful bottom of the differential list, province of the lethal and rare. However you try to resist, it alights instead on the minor, common stuff at the top, and waves away the problem. While sick strangers are a duty, a charge, and a puzzle to be solved, family members are precious jewels to be preserved from harm with talismans and wishful thinking.

Since the day I got my medical license, knowing these truths, I have never, not once, written a prescription for a family member. I sleep far better at night knowing someone else is responsible for diagnosing and treating my family. I have to think everyone is better off for it.